11/24/2014. Code category I21 for initial MI less than or equal to 4 weeks old Code category I22 for subsequent MI. 9.

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1 9.2 CVD Case Study I Angina see Arteriosclerosis, coronary (artery), native vessel with angina pectoris, unstable I Hemiplegia, following, cerebrovascular disease, cerebral infarction Z95.1 Status (post), aortocoronary bypass Acute Myocardial Infarction Code category I21 for initial MI less than or equal to 4 weeks old Code category I22 for subsequent MI Use when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI Must be used in conjunction with a code from category I21-never alone 149 Acute Myocardial Infarction I21.3, ST elevation (STEMI) myocardial infarction of unspecified site is default for unspecified MI If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI Old or healed MI not requiring further care is I

2 9.3 AMI Case Study Acute non-st anterior wall myocardial infarction suffered 5 days ago and atrial fibrillation I21.4 Infarct, myocardium acute with non ST elevation, 4 weeks or less (NSTEMI) I48.91 Atrial Fibrillation AMI Case Study Patient from previous case presents to ED two weeks later with acute inferior wall MI. She is still being monitored following her initial MI two weeks ago and is still suffering from atrial fibrillation I22.1 Infarct, myocardial acute, 4 weeks or less, recurrent I21.4 Infarct, NSTEMI I48.91 Atrial Fibrillation 152 Chapter 9 Take Away Point With all coding rule changes, very significant expansion of specificity and detail, the greatly increased complexity of the codes, and the frequency in which circulatory disorders are coded, this will likely be the most challenging chapter to master

CHAPTER 10 Diseases Of The Respiratory System (J00-J99) 154 Chapter Notes Respiratory condition described as occurring in more than one site that is not specifically indexed, classify to the lower

3 CHAPTER 10 Diseases Of The Respiratory System (J00-J99) 154 Chapter Notes Respiratory condition described as occurring in more than one site that is not specifically indexed, classify to the lower anatomical site (e.g. tracheobronchitis to bronchitis in J40) Additional codes required for some categories: To identify infectious agent or virus Associated lung abscess Underlying disease Tobacco use or exposure 155 Acute Exacerbation COPD and Asthma acute exacerbation Worsening or decompensation of a chronic condition Not equivalent to an infection superimposed on a chronic condition May be triggered by an infection

4 Influenza Code only confirmed cases due to certain identified viruses (J09 and J10) Suspected, possible or probable should be coded to J11, Influenza due to unidentified influenza virus (use caution when coding these, clarify if possible) 157 Ventilator Associated Pneumonia Only code based on provider documentation Additional code required to identify organism Do not use an additional code from categories J12-J18 to identify type of pneumonia UNLESS: Patient was admitted to hospital with one type of pneumonia and subsequently developed VAP (which would become a secondary diagnosis) COPD Case Study COPD with emphysema J43.9 Emphysema (remember that emphysema IS COPD) read the notes in the book more specific COPD is a generic code *Pay attention to includes and excludes notes

5 10.2 Asthma Case Study Moderate persistent asthma with status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease J45.42 Asthma, asthmatic, moderate persistent, with, status asthmaticus J44.1 Disease, lung, obstructive (chronic), with, acute, exacerbation NEC Pneumonia Case Study MSSA pneumonia J Pneumonia due to methicillin susceptible Staphylococcus aureaus (MSSA) URI/INFLUENZA Case Study Upper respiratory tract infection due to novel influenza A virus J09.X2 Influenza (bronchial) (epidemic) (respiratory) (upper) (unidentified influenza virus), due to identified novel influenza A virus, with, respiratory manifestations, NEC

Chapter 10 Take Away Point A coder must pay very close attention to the guidelines and notes in both the Alphabetic Index and the Tabular List in Chapter 10 to assign the correct codes 163 CHAPTER 11

6 Chapter 10 Take Away Point A coder must pay very close attention to the guidelines and notes in both the Alphabetic Index and the Tabular List in Chapter 10 to assign the correct codes 163 CHAPTER 11 Diseases Of The Digestive System (K00-K95) Hernia Case Study Patient with recurrent right inguinal hernia with gangrene and obstruction K40.41 Hernia, inguinal, with gangrene (and obstruction) recurrent Category note: Hernia with both gangrene and obstruction is classified to hernia with gangrene

7 11.2 Gastric Ulcer Case Study Acute gastric ulcer with hemorrhage K25.0 Ulcer, ulcerated, ulcerating, ulceration, ulcerative, gastric see Ulcer, stomach (eroded) (peptic) (round), acute, with, hemorrhage Crohn s Case Study Crohn s disease of small intestine with small bowel obstruction An additional code for the small bowel obstruction is not required as the combination code in ICD-10- CM identifies both the Crohn s disease and the small bowel obstruction. K Crohn s disease see Enteritis, regional, Enteritis (acute) (diarrheal) (hemorrhagic) (noninfective) (septic), regional (of), small intestine, with complication, intestinal obstruction 167 Chapter 11 Take Away Point This chapter looks and feels the same as ICD-9 but close attention must be paid to combination codes and instructional notes indicating the need for additional codes

CHAPTER 12 Diseases of the Skin and Subcutaneous Tissue (L00-L99) 169 Pressure Ulcer Stage Codes Combination codes that identify site and stage Severity designated by stages 1-4, unstageable and

8 CHAPTER 12 Diseases of the Skin and Subcutaneous Tissue (L00-L99) 169 Pressure Ulcer Stage Codes Combination codes that identify site and stage Severity designated by stages 1-4, unstageable and unspecified based on clinical documentation Any associated gangrene should be sequenced first Unspecified vs. unstageable No code is assigned for healed pressure ulcer Pressure Ulcer Case Study Patient with gangrenous pressure ulcer of right hip with cellulitis and pressure ulcer of sacrum documented by physician. Nursing assessment indicated stage 2 sacral ulcer and stage 3 decubitus ulcer of right hip

9 12.1 Pressure Ulcer Case Study I96 Ulcer, gangrenous, gangrene L Ulcer, pressure, Stage 3, hip L Ulcer, Stage 2, sacral L Cellulitis, lower limb 12.2 Stasis Ulcer Case Study Atherosclerosis of right ankle (native artery), with non-healing ulcer, with breakdown of skin Stasis Ulcer Case Study I Atherosclerosis, see also arteriosclerosis. Arteriosclerosis, arteriosclerotic (diffuse) (obliterans) (of) (senile) (with calcification), extremities (native arteries) leg, right, with ulceration (and intermittent claudication and rest pain), ankle L Ulcer, ulcerated, ulcerating, ulceration, ulcerative, lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic) (tropical) ankle, right, with skin breakdown only 58

10 12.3 Rash Case Study A patient with a rash on the trunk and upper extremities over the last 3-4 days due to Ramipril taken for hypertension. Physician discontinues Ramipril and prescribes Captopril and a topical cream for localized dermatitis Rash Case Study L27.1 Dermatitis, (eczematous) due to drugs and medicaments, (generalized) (internal use) localized skin eruption T46.4X5D Table of Drugs and Chemicals, Ramipril, Adverse Effect, initial encounter I10 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) Chapter 12 Take Away Point Chapter 12 is another chapter with extensive use of laterality; however, coders need to carefully understand the details in the combination codes for pressure and non-pressure ulcers

11 CHAPTER 13 Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) 178 Musculoskeletal System Most codes have site and laterality designations Site represents bone, joint or muscle involved Multiple sites codes Seventh Characters A initial encounter D subsequent encounter G subsequent encounter delayed healing K subsequent encounter nonunion P subsequent encounter malunion S sequela *****If code starts with M or S look for direction regarding 7 th characters 60

12 Aftercare Aftercare for broken bones will now be coded to fracture with 7 th character D in post acute care Pathological and stress fractures are found in this chapter Osteoporosis Use category M81, Osteoporosis without pathologic fx, for patients with osteoporosis who do not current have a pathologic fracture due to osteoporosis. patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow code M81 Pathological Fracture Use category M80, Osteoporosis with current pathological fracture, for patients who have a current pathologic fracture at the time of an encounter. DO NOT USE traumatic fracture code here this must be determined and documented by the physician. 61

13 13.1 Path Fracture Case Study An 80-year-old female with senile osteoporosis complaining of severe back pain with no history of trauma. Provider documentation reveals pathological compression fractures of several lumbar vertebrae. -M80.08XD Case Studies Bacterial Septic Arthritis -M00.80 Degenerative disc disease, lumbar region, with myelopathy -M51.06 Chapter 13 Take Away Point Although the detail in this musculoskeletal chapter is not that complicated, coders will need to pay very close attention when consulting the index and tabular due to the sheer volume of codes and the ease of miscoding from viewing so many similar codes. 62

CHAPTER 14 Diseases of the Genitourinary System (N00-N99) 187 Stages of Chronic Kidney Disease CKD classification based on severity designated by stages 1-5 End stage renal disease (ESRD) is assigned

14 CHAPTER 14 Diseases of the Genitourinary System (N00-N99) 187 Stages of Chronic Kidney Disease CKD classification based on severity designated by stages 1-5 End stage renal disease (ESRD) is assigned when it has been documented by the provider (Stage 5 requiring chronic dialysis) If both a stage of CKD and ESRD have been documented, assign the code for ESRD only Kidney Failure Case Study An 83-year-old man with complaints of lower abdominal pain and the inability to urinate over the past 24 hours, diagnosed as acute kidney failure due to acute tubular necrosis, caused by a urinary obstruction. The urinary obstruction was a result of the patient s benign prostatic hypertrophy

15 14.1 Kidney Failure Answer N17.0 Failure, kidney, acute w/tubular necrosis N40.1 Hypertrophy, prostate see enlargement, prostate with LUTS N13.8 Obstruction, urinary 14.2 UTI Case Study A 78-year-old female with fever, malaise, and left flank pain. A urinalysis shows bacteria of more than 100,000/ml present in the urine and subsequent urine culture shows Proteus growth as the cause of the urinary tract infection. The patient also has a history of repeated UTIs over the past several years UTI Case Study N39.0 Infection, infected, infective, (opportunistic), urinary (tract) B96.4 Infection, infected, infective (opportunistic), bacterial NOS, as cause of disease classified elsewhere, proteus (mirabilis) (morganii) Z History, personal (of), infection, urinary(recurrent) (tract) 64

Chapter 14 Take Away Point Chapter 14 Diseases of the Genitourinary System has changed very little in comparison to other chapters; however, coders must remain diligent in selecting codes to avoid

16 Chapter 14 Take Away Point Chapter 14 Diseases of the Genitourinary System has changed very little in comparison to other chapters; however, coders must remain diligent in selecting codes to avoid simple mistakes. 193 CHAPTER 15 Obstetrics (O00-O9A) Obstetrics Even though it is rare there are long term care providers that do care for pregnant moms Code the condition for which the patient is receiving care and any other diagnoses secondary Example: Fractured ankle, with secondary pregnancy

for which you are caring for the patient Cleft Palate, tube feeding, then any other secondary

17 CHAPTER 16 Certain Conditions Originating in the Perinatal Period (P00-P96) 196 Perinatal Codes Even though it may be rare to care for babies in long term care it does happen Code the diagnosis for which you are caring for the patient Cleft Palate, tube feeding, then any other secondary diagnoses 197 CHAPTER 17 Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99)

18 Congenital Malformations Assigned any time in a patient s life if being diagnosed or treated May be present at birth but not diagnosed until later in life If previously treated and resolved, code personal history code 199 Manifestations DO NOT code manifestations if they are inherent to the malformation/deformation/abnormality DO code manifestations that are not inherent EX: Down Syndrome Use F70-79 to further identify the intellectual disability 17.1 & 17.2 Case Study Down Syndrome -Q90.9 Septal heart defect -Q

Chapter 17 Take Away Point With the significant expansion of conditions and sites, coders will need to collect more detail on congenital conditions.

19 Chapter 17 Take Away Point With the significant expansion of conditions and sites, coders will need to collect more detail on congenital conditions. 202 CHAPTER 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings (R00-R99) 203 Signs & Symptoms Symptoms, signs, abnormal results and ill-defined conditions without a classifiable diagnosis Only use if definitive diagnosis has not been established May be used in addition to a definitive diagnosis as long as the sign or symptom is not routinely associated with that diagnosis

20 Signs & Symptoms R29.6, (repeated) falls when patient has recently fallen and the reason is being investigated Z91.81, History of falling when a patient has fallen in the past and is at risk for future falls May be assigned together 205 Example R53.2, Functional quadriplegia Lack of ability to use one s limbs or to ambulate due to extreme debility NOT associated with neurologic deficit or injury Fever Case Study Patient with fever of 101 degrees with chills. Lab tests and urinalysis are within normal limits. Physician gives final diagnosis as fever with chills, possible viral syndrome. R50.9 Fever (of unknown origin) (persistent)(with chills) (with rigor)

21 18.2 Pain Case Study Patient complaining of right upper quadrant abdominal pain in addition to nausea and vomiting. Patient also has elevated blood pressure readings, but diagnosis of hypertension is not made. Patient referred for follow up appointment Pain Case Study R10.11 Pain, abdominal, upper, right quadrant R11.2 Nausea, with vomiting R03.0 Elevated, elevation, blood pressure, reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension 209 CHAPTER 19 Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)

22 7 TH CHARACTERS A initial encounter Active treatment (surgical treatment, ED encounter, evaluation & treatment by new physician) D subsequent encounter Routine care during healing or recovery phase Aftercare Z codes are not used for aftercare for injuries or poisonings where 7 th characters are provided to identify subsequent care S sequela Complications or conditions arising as direct result of condition 211 Injuries Assign separate codes for each injury unless a combo code is provided Superficial injuries are not coded when associated with more severe injuries of same site Do not assign traumatic injury codes for normal, healing surgical wounds or complications of these 212 Aftercare Aftercare for broken bones will now be coded to Fracture with 7 th character D Traumatic fractures are found in this chapter 71

23 Traumatic Fractures A fracture not indicated as open or closed should be coded to closed A fracture not designated as displaced or non-displaced should be coded to displaced 7 th characters Some fractures have expanded 7 th characters to identify open fractures Compound fracture = open fracture 214 Fracture Specificity Greater specificity for fractures Type Specific site Displaced vs. non-displaced Routine vs. delayed healing Mal-union Type of encounter Elbow FX Case Study A patient admitted for aftercare following traumatic lateral epicondyle fracture of the right elbow, which is healing normally. S42.431D Fracture, traumatic (abduction) (adduction) (separation), humerus, lower end, epicondyle, lateral (displaced)

24 19.2 Hip Case Study A patient admitted following surgery for an infected right hip prosthesis. -T84.51XD Complication(s) (from) (of), joint prosthesis, internal, infection or inflammation, hip. Review the Tabular for complete code assignment and seventh character. 217 Adverse Effects Drug correctly prescribed and properly administered Code nature of adverse effect followed by the code for the cause in the Table of Drugs and Chemicals Tachycardia, delirium, vomiting, renal failure DO NOT code directly from the Table! Digoxin Case Study A patient taking Digoxin is experiencing nausea, vomiting and profound fatigue. The patient indicates that she has been taking the drug as prescribed. Evaluation and treatment focused on adjustment of medication only

25 19.3 Digoxin Case Study R11.2 Nausea, with vomiting R53.83 Fatigue T46.0X5D Table of Drugs and Chemicals, Digoxin, adverse effect Poisoning Error made in drug prescription Overdose of drug intentionally taken Non-prescribed drug taken with correctly prescribed and properly administered drug Interaction of drugs and alcohol 5 th or 6 th character shows intent Use additional code for manifestations of poisoning 221 Under-dosing Taking less than is prescribed by provider or manufacturers instruction inadvertently or deliberately Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.61, Y63.8- Y63.9) codes are to be used in addition to indicate intent, if known

CHAPTERS OF ICD-10-CM

CHAPTERS OF ICD-10-CM Chapter Description Category Chapter 1 Certain Infectious and parasitic diseases A00-B99 Chapter 2 Neoplasms C00-D49 Chapter 3 Diseases of the blood and blood-forming organs and certain